Name* First Last US Phone*International PhoneEmail* Rental Equipment Manual Wheelchair - USD 17.00/day Manual Heavy Duty Wheelchair - USD 18.00/day Beach Wheelchair Lounger - USD 26.00/day Beach Wheelchair 4 Wheels - USD 30.00/day Transport Wheelchair - USD 17.00/day Walker with Wheels - USD10.00/day Walker w/o Wheels - USD 10.00/day Rollator - USD 14.00/day Knee Rollator - USD 16.00/day 3 Wheel Heavy Duty Mobility Scooter - USD 28.00/day 4 Wheel Heavy Duty Mobility Scooter - USD 28.00/day Heavy Duty Rollator - USD 16.00/day 3 Wheel Mobility Scooter - USD 26.00/day 4 Wheel Mobility Scooter - USD 26.00/day Bath Chair - USD 9.00/day Transfer Bench - USD 10.00/day Oxygen Concentrator - USD 28.00/day Trapeze Bar - USD 14.00/day Ramp 2” - USD 12.00/day Ramp 4” - USD 14.00/day Ramp 6” - USD 16.00/day Commode option at - USD $14.00 Shower Chair/Commode with Wheels – USD $ 24.00/day Elevated leg Rest for Wheelchair- USD $1.00/day Cane Holder for Electric Scooter/ Wheelchair- USD $2.00/day Cup Holder for Scooter/ Wheelchair/ Walker- USD $1.00/day Stepping Stool $8.00/day Start Date End Date Users Weight (in LBS)Delivery LocationDelivery AddressDelivery Time: 1 time/day from 12:00-1:00pm : HH MM AM PM (No need to fill in time slot. In advance delivery of equipment available upon request with in advance payment arrangements.) Delivery Time Preference : HH MM AM PM (Please allow 2 hours after airport arrival time to avoid redelivery fee.) Delivery Time Preference : HH MM AM PM (Please allow 2 hours after airport arrival time to avoid redelivery fee.) Delivery Time Preference : HH MM AM PM (Please allow 2 hours after airport arrival time to avoid redelivery fee.) Pick-Up LocationPick-Up AddressPick up Time Preference : HH MM AM PM *A 7% local tax will be added to prices
